Providing a health service in a rural area comes with its challenges: limited medical resources, reliance on ambulance and rescue helicopter services and, especially in New Zealand, a stoic rugby culture with a fear of missing the next big game! Working in New Zealand’s Tasman region in the beautiful but remote Golden Bay has had its fair share of curve balls for our sports physiotherapy practice. It was one of those challenges that led to the development of the Concussion Conversations programme, aiming to better understand what information is wanted, needed and how it should be delivered to improve community understanding of sport-related concussion (SRC) and its acute management.

With the increasing awareness of concussion in contact sports, New Zealand sports policy makers have produced some good support information in the form of documents, handouts and videos, all freely available to the public.1–6 Yet, in rural areas, very few people are aware of these resources and even fewer access them.

The ‘Blue Card’ initiative was first trialled in New Zealand provincial rugby in 2014 and allows an appropriately trained referee to remove a player with a suspected SRC from the field of play for the duration of the game. In New Zealand, Rugby Union players are then stood down from play until symptom-free (minimum of 21 days for seniors), required to complete a return-to-play process and pass a medical sign-off prior to returning to the game. Having a supportive, knowledgeable medical and community network is paramount to the successful implementation of this programme.

The 2023 Tasman senior rugby season saw 29 players removed from play with ‘blue cards’ being issued, up from 24 in 2018 when this concussion management initiative was implemented. This increase in numbers is likely partly due to the improved referee awareness created by the Tasman Rugby Union, but it does not capture non-carded, missed or late-onset concussions. Given that just under half of the rugby players in rural communities live more than 30 min away from the local hospital, the importance of a supportive and well-educated community/whanau (family) cannot be undervalued.

Most people will have a rudimentary understanding of R.I.C.E./P.OL.I.C.E. or even PEACE and LOVE,7 8 meaning they can support someone with a basic injury at home and know when they need further input, but the same is not true for the general population’s understanding of the principles of SRC management.

Given the more nuanced approach required to meet the needs of a rural community, working with Tasman Rugby Union’s Head of Community Rugby, Kahu Marfell, has provided us with the information and reach to create and promote a community forum to help local doctors, players, coaches and whanau (families) appreciate why the injury needs to be taken seriously and review some of the information that is available to assist in management in the early stages of SRC.

The Concussion Conversation forum is a face-to-face group session consisting of an overview of the condition (provided by a relevant clinician), a review of some of the available guidance and return-to-play protocols, personal accounts from local players who have sustained an SRC and a guided discussion to establish what the community would like to learn and how they would like to become better informed.

Following the sessions, attendees’ feedback confirmed a better understanding of the potential consequences of concussion and increased interest in further education and training to assist coaches, managers, players, their whanau and the community in general to enable better recognition of SRC, appropriate management at home and faster presentation to hospital/medical services when indicated.

While there are plenty of resources available to help people better understand concussion, there are no available processes/resources looking specifically at improving engagement and general knowledge in rural communities where uptake of this information is generally poor.

Running a programme that starts with community engagement and then progresses to education/training increases the feeling of ownership for those who are involved and encourages others to fulfil leadership roles and promote the programme in their own and neighbouring communities. Through this process, the team has helped breach the knowledge gap between best practices and community needs.

While education from a qualified health professional is valuable and respected, hearing the stories from people within their own community, especially those with whom they can empathise and identify, has been reported as some of the most valuable aspects of the project to date. Commonly, people know each other in smaller, more tighter-knit communities, but due to the ‘invisible’ nature of SRC, it is often difficult to assess its personal impact.

An unexpected outcome from the programme was a strong indicator for more support groups to enable ongoing discussion and sharing. Almost all those with experience with SRC who attended confirmed a feeling of being alone in their condition, feeling that it is invisible and people don’t understand, and a concern about access to appropriate assessment and guidance in the acute period.

Moving into the 2024 rugby season, the information gathered will be brought together to tailor different education programmes for the different communities in our region. The long-term goal is to have more people help identify and support those who have a mild traumatic brain injury, get rid of the ‘it’s just a concussion’ attitudes and hand some ownership back to the community to run and engage in ongoing concussion education and management programmes in the future. Using Concussion Conversations, this innovative and collaborative approach has ensured knowledge translation and the implementation of region-specific best practices in concussion care.

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Thanks go to Kahu Marfell, Stephen Caunter, Jo MacLean and Tasman Rugby Union for their hard work in pulling together the data for our region, our local concussion sufferers for their input and a huge thank you goes to our local community for getting behind this project.